Welcome to our online clinic. This questionnaire forms the basis of today's consultation. Just as with your GP, we need you to be honest with your answers so we can prescribe medication safely.There is a fatal reaction between ED tablets and nitrate medication, including GTN spray.Do not buy ED medication from us if you have a GTN spray, gel or cream or take any nitrate tablets (usually prescribed for heart conditions). You need to see your GP to discuss alternative options.

PLEASE READ THIS STATEMENT, AND CHECK THE BOX IF YOU WISH TO PROCEED*

I DO TAKE NITRATE MEDICATION

I ACKNOWLEDGE THE ABOVE NOTIFICAITON, AND CAN CONFIRM THAT I AM NOT ON ANY NITRATE MEDICATION. I ALSO COMMIT TO ANSWERING QUESTIONS FULLY AND HONESTLY

Did your erectile dysfunction appear over a period of time, or suddenly?*

Do you ever get an erection?*

Do you know the cause of your ED?*

No

Age

Nerves / Stress / Tiredness

Depression

Medical Condition / Medication

Unhealthy lifestyle (i.e smoking / drinking)

Other

Have you previously been treated for ED?*

Which medication were you prescribed?*

Would you like to continue with the same treatment?*

Have you ever had prostate surgery or been diagnosed with any conditions of the prostate?

No

Yes

Do you have Peyronies disease?

No

Yes

Do you have any other deformity of your penis?

No

Yes

Are you circumcised?

No

Yes

Are you taking any prescription medicines?

No

Yes

Prescription Medicines*

Do you suffer any allergies?

No

Yes

Allergies*

Do you suffer from any conditions in which sexual activity is not advised?

Rosemount pharmacy began trading in the UK in 2010 and has progressed to partner with Simple Online Pharmacy to provide Online Pharmacy and Doctor services across the UK. Services are not intended as a replacement between you and your doctor, rather they are designed to support, and make more accessible certain services, should they be required. You should always read all product packaging and labels before use. If you have, or suspect you may have, a health problem you should consult your GP. Please also consult your GP or pharmacist before taking any new product, particularly if you are already under medical care.